Pinellas County, Florida - District Six Medical Examiner Office form

Application for Employment

This organization is an equal opportunity and Drug Free Workplace employer. We do not discriminate against any applicant for employment or employee with respect to hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment because of age, sex, race, color, religion, national origin, ancestry or physical handicap (except where based on a bonafide occupational qualification). Job applicants will be tested for the presence of drugs pursuant to Chapter 440.102 Florida Statutes.

Position(s) applied for: Date of Application

Name Social Security #

(Last) (First) (Middle)

Address

(Street) (City) (State) (ZIP)

Telephone Beeper/Cellular?

Have you ever been employed here before? If Yes, give position and dates. Yes No

Are you legally eligible for employment in the U.S.? Yes No

Date available for work Type of employment sought? Full-Time Part-Time

Driver's license number if driving is an essential job function.

Have you ever been arrested, pled "guilty" or "no contest", or been convicted of a crime? Yes No

If Yes, please provide dates and details on an attached sheet.

Have you ever used illicit drugs or abused prescription medications? If Yes, please provide explanation on an attached sheet. Yes No

Have you ever filed a worker's compensation claim? If Yes, give date(s) and reason for claim on an attached sheet. Yes No

Answering YES to these questions does not constitute an automatic bar to employment. Factors such as date of offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

From To

Employer Telephone #

Starting Job Title / Ending Title

Address

Immediate Supervisor and Title

Summarize the nature of the work and job responsibilities

May we contact for reference?

Yes No Later

Reason for Leaving

Salary or hourly rate	Start	Per-	Ending	Per-

From To

Employer Telephone #

Starting Job Title / Ending Title

Address

Immediate Supervisor and Title

Summarize the nature of the work and job responsibilities

May we contact for reference?

Yes No Later

Reason for Leaving

Salary or hourly rate	Start	Per-	Ending	Per-

From To

Employer Telephone #

Starting Job Title / Ending Title

Address

Immediate Supervisor and Title

Summarize the nature of the work and job responsibilities

May we contact for reference?

Yes No Later

Reason for Leaving

Salary or hourly rate	Start	Per-	Ending	Per-

Skills and Qualifications

Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Educational Background

(if Job Related)

	Name and Location	# Years	Did you graduate?	Degree?	Course of Study
High School			Yes No	Yes No
College			Yes No	Yes No
Other			Yes No	Yes No

References

Name and Address	Telephone	Years Known

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and accurate.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies including a criminal background check and credit history, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in the application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. Further, it is the position of the employer that it is a condition of employment to refrain from reporting to work or working with the presence of drugs or alcohol in my body [Section 440.101(2) Florida Statutes]. This employer performs drug testing and will provide me with a copy of the Drug Free Workplace Policy.

I understand that this application remains current for only 90 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it may be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law because this employer is, himself, an at-will appointee. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer as president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.

WARNING: Do NOT sign below until you have read the above statement and are notarized.

I certify that I have read, fully understand and accept all terms of the forgoing Applicant Statement.

_________________________________ ____________________

Signature Date

STATE OF FLORIDA

AFFIDAVIT

COUNTY OF PINELLAS

The forgoing instrument was acknowledged before me this _________ day of ___________________, 20___ by _____________________________________, who is personally known to me or has produced ____________________________ as identification and who did (did not) take an oath.

(Signature) __________________________________

(Name) __________________________________

* E-mail address

* required to submit form. By completing this form and providing my email address, I certify that all information provided is accurate, true and complete

E-mail addresses are public records under Florida law and are not exempt from public-records requirements. If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity. Instead, contact this agency by telephone at (727-582-6800) or in writing, via the United States Postal Service at 10900 Ulmerton Rd., Largo FL 33778.